Anaesthesia for Plastic and Reconstructive surgery. Burn trauma. Francois Stapelberg, FANZCA. 19 th June 2018 Auckland ANZCA Part 2 short course

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1 Anaesthesia for Plastic and Reconstructive surgery Burn trauma Francois Stapelberg, FANZCA Department of Anaesthesia, Middlemore Hospital New Zealand National Burns Centre 19 th June 2018 Auckland ANZCA Part 2 short course

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3 A 23 year old male is scheduled for limb salvaging reconstructive surgery after sustaining massive lower leg trauma from a motor vehicle accident seven days previously. Surgery time is expected to be 18 hours. External fixateurs were applied at that time because the wounds were contaminated. Discuss the issues that you might encounter.

4 A 23 year old male is scheduled for limb salvaging reconstructive surgery after sustaining massive lower leg trauma from a motor vehicle accident seven days previously. Surgery time is expected to be 18 hours. External fixateurs were applied at that time because the wounds were contaminated. Discuss the issues that you might encounter.

5 A 23 year old male is scheduled for limb salvaging reconstructive surgery after sustaining massive lower leg trauma from a motor vehicle accident seven days previously. Surgery time is expected to be 18 hours. External fixateurs were applied at that time because the wounds were contaminated. Discuss the issues that you might encounter. Positioning Pressure cares Lines, IDC, arterial line Fluid management Temperature Thromboprolylaxis Team fatigue

6 Anaesthesia for microvascular surgery Flow Hagen Poiseuille: pressure gradient, viscosity, radius, length of tube Laplace: transmural pressure Shear stress Arterial pressure control Hypervolemic haemodilution Normocarbia Temperature control Positioning Pain control Long anaesthesia time

7 Failing flaps Decreased blood flow through flap Hypothermia Warm ischaemia Vasoconstriction Pain Hyperventilation: resp alkalosis, cardiac output, peripheral vasoconstriction Hypoventilation: Resp acidosis, reduced red cell deformability Hyperoxia : vasoconstriction, reduced functional capillary density Core-periphery gradient >2 C Balanced anaesthesia, regional, TIVA vs inhalational Avoid shivering

8 A 65 year old female patient is two hours into debridement and skin grafting for a 40% burn to her thorax and legs. She is intubated and paralysed. An arterial blood gas now shows: ph 7.12 PaO2 150 PaCO2 45 HCO3 15 K 6.3 a. Outline the potential causes for this patient s hyperkalaemia. b. Describe your management of this hyperkalaemia. Borderline Candidate Part A Relates the causes to the large burn pathology. (30%) (70%). Mentions two contributors to hyperkalaemia that are considered significant (e.g. tissue damage and renal impairment) Part B Demonstrates a logical management pathway Provides sufficient detail for the examiner to identify: (a) the candidates trigger for management of hyperkalaemia in this patient, (b) initial therapy that would work in this scenario.

9 Cleft lip and palate 1 in 600 to 700 live births 4 th most common congenital defect 70% non syndromic, isolated defect Timing of surgery 4% of cleft children have cardiac defect Difficult intubations likely: Treacher Collins Pierre Robin sequence Stickler, velocardiofacial, foetal alcohol Hemifacial microsomia (Goldenhaar)

10 Syndromes and difficult airways Improves with age Pierre-Robin sequence (micrognathia, jaw size increases) Goldenhar (asymmetrical micrognathia, jaw size increases) Worsens with age Treacher-Collins syndrome (micrognathia, small mouth, funnel shaped larynx) Apert (midface anomalies, cervical fusion) Hunter and Hurler syndrome (mucopolysaccharide accumulation in tongue and larynx) Beckwith-Wiedemann (macroglossia) Freeman-Sheldon syndrome (circum-oral fibrosis and microstomia)

11 Craniofacial syndromes Craniosynostosis Apert, Crouzon, Pfeiffer, Saethre-Chotzen, Jackson-Weiss, Carpenter, Antley-Bixler Abnormal contour Encephalocele (with absent corpus callosum, clefting, Dandy-Walker and Arnold-Chiari malformations, ectrodactyly, and hypothalamic-pituitary ysfunction) Orofacial clefting Facial clefts and associated anomalies, Tessier clefting system, lateral facial clefts, oblique facial clefts, and median mandibular defects Branchial arches Unusual facies Goldenhar, Treacher Collins, Nager, Miller, Wildervanck, Bixler, Möbius, and orofaciodigital syndromes (I-VIII) Opitz BBB, Opitz G, Noonan, Robinow, Binder, and Coffin-Siris

12 Anaesthesia for plastics and reconstructive surgery Complex wound closure Musculocutaneous flaps Free flap tissue transfers Re-implantation microsurgery Congenital reconstructive surgery Cleft lip and palate surgery Craniofacial surgery Cancer surgery Pressure ulcers Burns Aesthetic surgery

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14 Anaesthesia for BURN trauma Francois Stapelberg, FANZCA Department of Anaesthesia, Middlemore Hospital New Zealand National Burns Centre 19 th June 2018 Auckland ANZCA Part 2 short course

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19 Wildfires 2017, NASA satellite imagery

20 What is the question? Primary issue Other issues What is your plan? BE SAFE Communicate Follow up

21 Modern burn care ABCDE Resuscitate and prevent burn shock Early wound excision and covering with autograft skin hypermetabolism mortality Manage inflammatory responses Prevent infection Pain management Nutritional support Psychological support Rehabilitation

22 Decompressive surgery Escharotomy Fasciotomy Laparotomy Early burn wound excision Surgical airway/tracheostomy Damage control surgery Fracture stabilisation Acute burn care

23 Burn phases Anaesthetic involvement may be in one of 3 phases: Resuscitation Acute debridement and skin grafting Reconstruction and scar revision.

24 Emergency Management of Severe Burns L O O K D O A I R W A Y C spine B R E A T H I N G O 2 C I R C U L A T I O N Haemorrhage control & I.V. access D I S A B I L I T Y AVPU & Pupils Primary Survey E X P O S U R E Environmental Control (& Estimate TBSA) FLUIDS ANALGESIA TESTS TUBES Check First Aid A.M.P.L.E. History Head to Toe Examination Tetanus Documentation Referral Support Secondary Survey

25 Inhalation injury Classification Airway above larynx hot gases, potential for worsening Airway below larynx inhaled products of combustion Systemic effects, CO, cyanide History Examination Nasendoscopy Indications for intubation Worsening airway status Oxygenation failure Airway protection Transport time to burn centre

26 Estimating burn size Lund Browder charts Rule of NINES Palm area =1% Children have large head Age < 10 18%, subtract 1% each year of life, add to legs

27 Haemocromogenuria Extensive deep burns Electrical injury Blunt trauma Reperfusion injury Increased volume resuscitation Aim to increase urine output mL per hour 2ml/kg/hour in children Mannitol could be considered

28 Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Perel P, RobertsI, Ker K Thisisareprint of acochranereview, preparedandmaintainedbythecochranecollaborationandpublishedinthecochranelibrary 2013, Issue2 Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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30 First 24 hours Balanced crystalloid solution Hartmann s (or Plasmalyte or Lactated Ringers) Avoid giving boluses Resuscitation failure, consider adding: Vasopressin Noradrenaline Estimate 24 hours fluids Consider early albumin at 12 hours Bladder pressures, consider abdominal decompression At 24 hours, and absence of shock: Titrate fluid resuscitation down to maintenance Consider adding albumin mL/kg/TBSA BURN resuscitation: What fluids, and when?

31 Metabolic modulation Stress response to injury effects: Cuthbertson classic ebb and flow ambient temperature effects nutrition hormonal modulation growth factors and cytokines GH/Growth hormone binding protein complex platelet derived growth factor fibroblast growth factor transforming growth factor epidermal growth factor topical growth factor application GH/insulin like growth factor axis systemic GH effects in burns insulin like growth factor -adrenergic-receptor blockers: propranolol anabolic steroids, oxandrolone

32 Nutrition support Hypermetabolism REE rates increase 30% Hyperpyrexia Acute phase proteins glucose levels, insulin resistance Feed early (24-48 hours) Enteral route, post-pyloric preferred Minimise interruption Continue NJ feeds throughout surgery

33 Survival prediction Baux score Age + TBSA Age +TBSA + 17 (inhalational burn) Burn size >40% (RR12) Age >50 (RR 7.3) Inhalation injury (RR 3.6) Male (RR 1.8)

34 ANZBA referral criteria to a burn centre TBSA criteria >10% in adults >5% in children >5% fill thickness burns Inhalational burn Special areas Face/Hands/Feet/perineum/circumferential/overlying major joints Electrical burns Chemical burns Extremes of age Co-morbidity Major trauma with burns Burn following assault (Non-accidental injury)

35 Anaesthetic planning Assessment Airway plan Fluid and blood requirements Pharmacological changes Monitoring difficulties Vascular access Pain management Nutritional interruption

36 Airway planning Facemasks slide off their ( sore ) face Gel pad mask donuts Gauze pads LMA s can be your get out-of-jail-free-pass Videolaryngoscopes (Glidescope ) Low threshold for awake fibre-optic intubation Neck contractures Woody submental tissue Fixation problems Interdental wire the ETT to a Maxillary screw Have a plan B, C, and a surgeon nearby

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38 Maxillary fixation technique

39 Resin bonded technique Maxillary incisors Wires to secure oral ETT

40 Minimise bleeding during burn surgery Early wound excision Tumescent infiltration Adrenaline 1:500,000 solution Local anaesthetic agent Topical adrenaline Algae preparations Positioning Tourniquets Tranexamic acid Transfusion triggers Be prepared Vascular access

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42 Pharmacology of burns AChR upregulation Avoid using suxamethonium after 48 hours post-burn Safe again 1-2 years post-burn, or wound closure, mobilising, absence of sepsis Non depolariser resistance Cardiac output changes Decreased renal clearance Opioid tolerance Ketamine

43 Pharmacology of burns AChR upregulation Avoid using suxamethonium after 48 hours post-burn Safe again 1-2 years post-burn, or wound closure, mobilising, absence of sepsis Non depolariser resistance Cardiac output changes Decreased renal clearance Opioid tolerance Ketamine

44 You are called to assist with the resuscitation of an 35 year old male electrician injured in a electrical explosion. He has respiratory distress. Outline your initial planning.

45 What is the question? Primary issue Other issues What is your plan? BE SAFE Communicate Follow up

46 Emergency Management of Severe Burns L O O K D O A I R W A Y C spine B R E A T H I N G O 2 C I R C U L A T I O N Haemorrhage control & I.V. access D I S A B I L I T Y AVPU & Pupils Primary Survey E X P O S U R E Environmental Control (& Estimate TBSA) FLUIDS ANALGESIA TESTS TUBES Check First Aid A.M.P.L.E. History Head to Toe Examination Tetanus Documentation Referral Support Secondary Survey

47 Emergency Management of Severe Burns L O O K D O A I R W A Y C spine B R E A T H I N G O 2 C I R C U L A T I O N Haemorrhage control & I.V. access D I S A B I L I T Y AVPU & Pupils Primary Survey E X P O S U R E Environmental Control (& Estimate TBSA) FLUIDS ANALGESIA TESTS TUBES Check First Aid A.M.P.L.E. History Head to Toe Examination Tetanus Documentation Referral Support Secondary Survey

48 NPDGB Children Victims of abuse Trauma victims Self harm with immolation Brave pilots Elderly frail patients P-lab cooks and their clients and the list goes on

49 What is the question? Primary issue Other issues What is your plan? BE SAFE Communicate Follow up

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